Impact of baseline symptom burden as assessed by patient-reported outcomes on overall survival of patients with metastatic gastrointestinal cancer
Patients diagnosed with metastatic gastrointestinal (GI) cancer have variable symptom burden. However, serial symptom assessments are time-consuming and may be challenging to implement in routine clinical practice. We aimed to determine if a single measurement of symptom burden at the time of diagnosis of metastatic GI cancer is associated with survival outcome.
We examined prospectively collected baseline patient-reported outcomes (PROs) of patients diagnosed with metastatic esophageal, stomach, pancreatic, and colorectal cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire from a large Canadian province between 2016 and 2019. The ESASr was categorized into physical (PH), psychosocial (PS), and total symptom (TS) domains. While PH score included six individual domains- pain, tiredness, drowsiness, nausea, loss of appetite, and shortness of breath, PS score consisted of two domains- anxiety and depression. The TS was derived from the domains in PH, PS, and a domain of overall well being. Each domain was scored from 0-10 by the patient and the scores were classified as mild (0-3), moderate (4-6), and severe (7-10). PS, PH, and TS were calculated by averaging the sum of all the individual domains. Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on OS to account for the baseline confounding factors.
We identified 810 patients, of whom 63% were men and median age was 67 (interquartile range, 29-91) years. There were 146, 142, 207, and 315 patients with esophageal, gastric, pancreatic, and colorectal cancer, respectively. Approximately one-third of all patients reported moderate to severe PH, PS, and TS scores, with pancreatic cancer patients experiencing the highest symptom intensity across all domains (P< 0.0001). The lowest symptom scores were observed in patients with colorectal cancer, and those with gastric and esophageal cancer had similar symptom scores. While age did not affect the symptom scores, females were more likely to report severe PH, PS, and TS scores (P=0.03, 0.02, and 0.03, respectively). On multivariable Cox regression analysis, while severe PH and TS scores, older age (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.03-1.08; P< 0.0001), and female sex (HR, 1.78; 95% CI, 1.49-2.06; P< 0.0001) were predictive of worse OS, PS scores were not related to outcomes.
A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step toward PRO collection for settings in which serial measurements have been challenging to implement.
Legal entity responsible for the study
Has not received any funding.
The presenting author has declared no conflicts of interest.